EARLY ONSET AGGRESSIVE BEHAVIOR INDUCED BY PERAMPANEL IN THE TREATMENT OF CHRONIC INSOMNIA: A CASE REPORT

Introduction Chronic insomnia, resistant to different treatments (pharmacological, sleep hygiene and cognitive-behavioral therapy) remains one of the greatest challenges in our daily practice as psychiatrists. The pharmacological options include benzodiazepines and their analogues (zolpidem, zopiclone, etc.). However, when trying to treat chronic insomnia the use of off-label drugs, including antidepressants with sedative action (such as trazodone), antipsychotics or antiepiletic drugs, is not uncommon. Perampanel is a non-competitive AMPA receptor antagonist, marketed for the treatment of partial onset epilepsy and primary generalized tonic-clonic seizures. It has been used in the treatment of chronic insomnia with positive results and it has shown to improve the quality of sleep in a recent observational retrospective cohort study. The most frequent adverse effects of Perampanel include dizziness and drowsiness. Perampanel can also cause psychiatric and behavioral adverse effects, aggression and irritability in up to 10% of patients, as well as depression, and suicidal ideation, with higher rates in patients with psychiatric history. Objectives To draw attention to possible adverse effects of Perampanel and to add knowledge to improve the treatment for chronic insomnia. Methods Case report and non-systematic literature review of the current data. Results A 33 year old woman with Anorexia Nervosa was admitted to the psychiatric hospitalization unit due to suicidal ideation and a history of chronic insomnia. Perampanel was started at a dose of 2mg/day, progressively titrated to 6mg/day, following patient’s informed consent. A week after the initiation of treatment, her sleep pattern had improved but she became aggressive, showed low tolerability to minor frustrations and suffered from an intensification of suicidal ideation. She became extremely hostile to the personnel, had severe tantrums and deliberate self injurious behavior. Perampanel was discontinued and in less than a week her aggressive behavior succumbed. Although she was not re-exposed to Perampanel the symptoms she presented are considered a very likely adverse drug reaction. Levomepromazine 20mg/day and Lormetazepam 0.5mg/day were reinstated as a treatment for insomnia. Conclusions Psychiatric comorbidity is known to be a risk factor for behavioral adverse effects of Perampanel. Therefore Perampanel as a treatment for chronic insomnia needs a careful individual benefit-risk assessment and monitoring for adverse effects. Disclosure of Interest None Declared

Introduction: Gender dysphoria is defined as a multisystemic medical condition in which a person has a marked mismatch between their biological sex and the gender with which they identify. Objectives: To highlight the psychological impact and social repercussions of gender dysphoria and to discuss the different aspects of management aimed at optimising a better quality of life for these patients. Methods: We describe the clinical cases of 5 patients followed at the child psychiatry department and the adolescent diagnostic centre of agdal, who were diagnosed with gender dysphoria. Results: Clinical vignette: -A.B: 15-year-old patient, followed in our training for a recurrent depressive disorder comorbid with borderline personality and gender dysphoria. This patient is a victim of school bullying altering his psychosocial functioning and generating thoughts of death.
-H.A: 16 year old patient, followed in our training for gender dysphoria comorbid with adrenal hyperplasia, indicating feminization surgery. -I.D: 17 year old female patient, victim of sexual assault, admitted to our training for suicide attempt. She presents a gender dysphoria, comorbid with a borderline personality. -C.G: 22 year old patient, followed in our training for gender dysphoria comorbid with a panic disorder. She is a patient describing an anxious experience with dysthymia. -L.K: 23-year-old patient, followed in our training for gender dysphoria. He is a patient who would have been a victim of verbal and physical aggression generating a post-traumatic stress disorder having had a significant impact on his socioprofessional life. Conclusions: Primary care physicians need to be aware of genderrelated disorders and the importance of early recognition of these emerging disorders. A multidisciplinary approach is needed to manage these disorders. Introduction: Chronic insomnia, resistant to different treatments (pharmacological, sleep hygiene and cognitive-behavioral therapy) remains one of the greatest challenges in our daily practice as psychiatrists. The pharmacological options include benzodiazepines and their analogues (zolpidem, zopiclone, etc.). However, when trying to treat chronic insomnia the use of off-label drugs, including antidepressants with sedative action (such as trazodone), antipsychotics or antiepiletic drugs, is not uncommon. Perampanel is a non-competitive AMPA receptor antagonist, marketed for the treatment of partial onset epilepsy and primary generalized tonic-clonic seizures. It has been used in the treatment of chronic insomnia with positive results and it has shown to improve the quality of sleep in a recent observational retrospective cohort study. The most frequent adverse effects of Perampanel include dizziness and drowsiness. Perampanel can also cause psychiatric and behavioral adverse effects, aggression and irritability in up to 10% of patients, as well as depression, and suicidal ideation, with higher rates in patients with psychiatric history. Objectives: To draw attention to possible adverse effects of Perampanel and to add knowledge to improve the treatment for chronic insomnia. Methods: Case report and non-systematic literature review of the current data. Results: A 33 year old woman with Anorexia Nervosa was admitted to the psychiatric hospitalization unit due to suicidal ideation and a history of chronic insomnia. Perampanel was started at a dose of 2mg/day, progressively titrated to 6mg/day, following patient's informed consent. A week after the initiation of treatment, her sleep pattern had improved but she became aggressive, showed low tolerability to minor frustrations and suffered from an intensification of suicidal ideation. She became extremely hostile to the personnel, had severe tantrums and deliberate self injurious behavior. Perampanel was discontinued and in less than a week her aggressive behavior succumbed. Although she was not re-exposed to Perampanel the symptoms she presented are considered a very likely adverse drug reaction. Levomepromazine 20mg/day and Lormetazepam 0.5mg/day were reinstated as a treatment for insomnia. Conclusions: Psychiatric comorbidity is known to be a risk factor for behavioral adverse effects of Perampanel. Therefore Perampanel as a treatment for chronic insomnia needs a careful individual benefit-risk assessment and monitoring for adverse effects. Introduction: Sleep related sexual behaviors or sexsomnias are unconscious behavioral activities that occur during sleep (e.g. parasomnias). Behaviors could range from sexual vocalizations, orgasms, sexualized movements, masturbation, or full sexual intercourse with a subsequent amnesia. Early epidemiological studies showed a prevalence of 7.1%, with a male predominance. While intended as a rare condition, leads to important physical and psychological consequences for both the patient and their bed partner. For our knowledge this is the first case of sexsomnia reported in Portugal. Objectives: To report the clinical and psychosocial impact of a Sexsomnia case in a young woman which was misdiagnosed with depression. Methods: Patient´s clinical files consultation and literature review using Pubmed â and the keywords: sexsomnia. Results: A 18-year-old female referred to a psychiatric consultation to be assessed and treated from a diagnostic of depressive disorder. This was a young woman with a previous history of sleepwalking during childhood, with no recurrent episodes since adolescence. A familiar positive history for sleepwalking was confirmed (mother). She reported the beginning of her sleep related sexual behavior six months before the consultation, conflicting with the moment in which she started pharmacological therapy for Chron Disease, diagnosed at that time. After she slept with her boyfriend, she was told by him about the recurrence of masturbatory activity during sleep. These episodes were told to occur as often as 1 to 2 times a night, shortly after falling asleep, with posterior amnesia for the event.

Disclosure of
As for medical or psychiatric history, only Chron's disease is highlighted, being under control with azathioprine. Likewise, he took 1mg of melatonin/night. Pittsburgh Sleep Quality Index at presentation was 7/21 and the STOP-Bang questionnaire revealed a low risk of Obstructive Sleep Apnea. A Type I Polysomnographic study was performed revealing decreased sleep efficiency and fragmented sleep presenting an alternating cyclic pattern. The existence of significant respiratory events during sleep, as well as periodic movements, was excluded. Cognitive behavioral therapy by means of highlighting the need of improvement on sleep hygiene measures was prescribed and the dose of melatonin was increased up to 3mg. Despite the good clinical response, the patient discontinued the melatonin treatment mainly due to familiar and personal reasons and failed to comply with the prescribed hygienic measures, with a further worsening of the clinical condition.
Conclusions: This particularly challenging case representing the emerging medicolegal issues and psychosocial aspects related with the still poorly understood sleep disorders like sexomnia, shows up how much awareness is required from psychiatric team members to better assist and refer patients, promoting both an assertive diagnostic and an effective management.

EPV1052
Moderating effect of sleep quality on the association between hospital anxiety and quality of life in patients with mild to moderate dementia; A cross-sectional study K. Bosak 1,2 *, I. Filipčić 1,2,3 , Ž. Bajić 1 and V. Grošić 1,2 Introduction: Anxiety and sleep disorders are common and associated comorbidities of dementia. Previous studies has proven the association between anxiety and sleep disorder with a reduced quality of life in hospitalized patients with dementia. However, it is not clear whether the sleep disorders change the association between anxiety and quality of life. Objectives: To test the hypothesis that sleep quality modify the association between anxiety and quality of life in hospitalized patients with mild or moderate dementia. Methods: We performed this cross-sectional study during 2017 at University Psychiatric Hospital "Sveti Ivan", Zagreb, Croatia. Data were collected on a consecutive sample of patients diagnosed with mild or moderate dementia. The outcome was the association between anxiety measured using the Hospital Anxiety and Depression Scale, and quality of life measured using the EQ-5D-5L visualanalogue scale. The independent variable was sleep quality measured using the Pittsburgh Sleep Quality Index (PSQI). We performed a moderation analysis using the Johnson-Neyman technique as implemented in Andrew F. Hayes macro "Process" Template 1, after adjusting for age, gender, education, body mass index, age at the time of onset of dementia, duration of